Provider Demographics
NPI:1891180089
Name:JACKSON MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:JACKSON MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-246-1154
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:GROVE HILL
Mailing Address - State:AL
Mailing Address - Zip Code:36451-0250
Mailing Address - Country:US
Mailing Address - Phone:251-246-1154
Mailing Address - Fax:251-246-1108
Practice Address - Street 1:220 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:AL
Practice Address - Zip Code:36545-2459
Practice Address - Country:US
Practice Address - Phone:251-246-1154
Practice Address - Fax:251-246-1108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH67212Medicare UPIN